ATI RN MED SURGE PROCTORED EXAM

I am limiting my intake of fast foods." is correct. Fast foods typically are prepared with high sodium and high fat, which increase the risk of atherosclerosis and coronary artery disease. To promote cardiovascular health, clients should select healthier food options, such as fruits and vegetables, or foods prepared by baking or broiling. 62. A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.) INCORRECT 1) Add the amount of bladder irrigation to the total output. 2) Use sterile technique when preparing the irrigation solution. 3) Make sure the drainage tubing is patent and without obstruction. INCORRECT 4) Contact the surgeon if the client reports a continual need to void. 5) Notify the surgeon if the urine is bright red or has large clots. Answer Rationale: Add the amount of bladder irrigation to the total output is incorrect. The nurse should subtract the amount of bladder irrigation solution from the total urine output amount. For example, if the total urine output is 2,500 mL and the amount of irrigation is 1,000 mL, the nurse should subtract 1,000 from 2,500 and record 1,500 mL as the total urine output. Use sterile technique when preparing the irrigation solution is correct. Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. Many clients who undergo a TURP are older adults who may have other chronic diseases that increase their susceptibility to infection. The nurse should observe these clients closely for manifestations of infection, such as fever and elevated WBC counts. Make sure the drainage tubing is patent and without obstruction is correct. For continuous drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the volume of fluid in the drainage bag. The nurse should make sure the drainage tubing is patent and without obstruction or kinks. This ensures a continuous, even irrigation of the catheter system. It prevents accumulation of solution in the bladder, which can cause bladder distention and possible injury. Contact the surgeon if the client reports a continual need to void is incorrect. The post-TURP catheter is large; the surgeon pulls it taut and secures it to the client’s leg. This provides traction that holds the catheter balloon against the internal sphincter of the bladder. As a result, the client probably will feel a continual need to void. The nurse should tell the client to expect this urge to void. However, the client should not attempt to void around the catheter because this can cause bladder spasms, which can be painful and can initiate bleeding. ................................................................................................CONTINUE